Nicotine Patch Prescription Protocol
The recommended protocol for prescribing nicotine patches is to start with a 21 mg/24-hour patch for most smokers, combined with a short-acting NRT form (gum, lozenge, inhaler, or nasal spray) for a minimum of 12 weeks. 1
Dosing Selection
- Start with a 21 mg/24-hour patch for smokers who consume ≥10 cigarettes per day 1
- For lighter smokers (<10 cigarettes per day), consider starting with a lower dose patch 1
- If the 21 mg patch is not effective in controlling cravings, consider increasing to 35 or 42 mg patch by using multiple patches 1, 2
- The 24-hour patch provides superior craving control compared to 16-hour patches, particularly for morning cravings 3
Combination Therapy
- Combination NRT (patch + short-acting NRT) is more effective than monotherapy and is recommended as first-line treatment 1, 4
- Short-acting NRT options to combine with patches include:
- Nicotine gum (2 mg or 4 mg)
- Nicotine lozenge
- Nicotine inhaler
- Nicotine nasal spray 1
- Combining different forms of NRT is both safe and effective 1
Treatment Duration
- Prescribe for a minimum of 12 weeks for the initial quit attempt 1, 4
- Therapy may be extended up to 6-12 months to promote continued cessation if needed 1
- Blood nicotine levels from NRT are significantly lower than from smoking cigarettes, making nicotine toxicity rare 1
Administration Instructions
- Apply the patch to clean, dry, hairless skin on the upper body or outer arm each morning 1
- Rotate application sites daily to prevent skin irritation 1
- The patch should be worn for 24 hours for optimal craving control, especially for managing morning cravings 3
- Instruct patients to follow package instructions and seek advice from healthcare providers if more information is needed 1
Follow-up Protocol
- Schedule follow-up within 2 weeks after starting pharmacotherapy (can be extended to 3 weeks to coordinate with regular appointments) 1, 4
- Conduct additional periodic follow-up during therapy at minimum 12-week intervals 1
- Monitor for nicotine withdrawal symptoms, which typically peak within 1-2 weeks of quitting 1
- Track attempts at smoking reduction and consider adjusting therapy if reduction efforts stall 1
Special Considerations
- NRT appears to be safe for patients with cardiovascular disease, though package inserts may advise consultation with a healthcare provider 1
- For pregnant smokers, the benefits of NRT likely outweigh the risks of continued smoking, but consultation with an obstetrician is recommended 1
- Some NRT products are not recommended for people under 18 years of age 1
- Very few people become addicted to NRT; some ex-smokers continue use for a year or more primarily due to concerns about returning to smoking 1
Common Pitfalls and Solutions
- Inadequate dosing: Ensure patients use sufficient nicotine doses to control withdrawal symptoms 1, 5
- Premature discontinuation: Encourage continued therapy even through brief slips 1
- Insufficient treatment duration: Maintain treatment for at least 12 weeks 1
- Failure to combine with behavioral support: Consider progressively intensifying behavioral therapy for patients who struggle to quit 1
- Underestimating morning cravings: The 24-hour patch provides better control of morning cravings than 16-hour formulations 3